Rheumatoid Arthritis Physiology

Rheumatoid Arthritis PhysiologyIntroductionRheumatoid Arthritis (RA) is defined as a chronic, autoimmune condition that affects 400,000 people in the UK (Cooney et al. 2010). It is both symmetrical and symmetrical in pattern and is typically presented in individuals between 30 to 50 years with females being more afflicted than men (Cooney et al. 2010).Although, RA is of unk instantern aetiology, ca practice sessions atomic number 18 express to be both genetic and environmental in nature (Abhishek et al.2010). More specifically, inflammation, in bodily function and loss of mechanical st tycoon around joints plays a utilisation in ca use pain, stiffness and pomposity of multiple joints. Consequently, long-term effects of RA been associated with reduced muscle intensity aim (Ekbolm et al. 1974) and aerophilous capacity (Minor et al. 1988).Currently, there is no cure for RA and therefore, precaution emphasizes on change magnitude symptoms and promoting quality of life through each drug Modifying Anti-Rheumatic drugs (DMARDs) or physiotherapy (Arthritis look for, UK). Indeed, DMARDs are a first line interpellation for RA however, not e preciseone responds adequately to DMARDs (Smolen and Keystone, 2012) and RA patients usually refrain from use this due to the potential occurrence of life-threatening side-effects (Kinder et al. 2005).Today, physiotherapy for those with RA constitute of many passive interventions such as patient education, delivery of cordiallyth or cold, massage and electro-magnetic energy (Wasserman,2011). However, despite earlier fear of incitement of symptoms, increased illness activity and joint damage, there is now scientific evidence showing that exploit is base hit and beneficial making it an jussive mood part of rehabilitation (Stenstrom and Minor, 2003).Specifically, the to the gamyest degree valued by RA patients is hydropathy handling ( third house et al. 1996) due to its ability to alleviate symptoms suddenly t hrough workout in water. The use of water properties such as buoyancy and warm temperatures enables patients to move freely through decreased weight bearing on joints, increased range of motion and reduced pain (Campion, 1997). Although, hydropathy is evolution epochally in popularity, writings in regards to the effectiveness of Hydrotherapy for RA has not been evaluated adequately.For example, Eversden et al. (2007) concluded that the Hydrotherapy group reported a great perceived benefit in comparison to the land-based exercise group afterward six weeks.Importantly, these authors conducted a fairly well-designed theatre of operations in that they took some precautions to evanesce bias through true randomization and concealment processes. However, these findings were not reflected in the physical functional or pain scores. Alongside this, there was a great payoff of participants in the Hydrotherapy group compared to the Land-based group preeminent to potential biases.Seco ndly, Hall et al. (1996) be that all groups assessed (Hydrotherapy, Seated Immersion, Land performance and Progressive Relaxation) demonstrated joint tenderness and pain relief. However, Hydrotherapy presented the around improvements (26% mean decrease) after 4 weeks manipulation.This study demonstrates strengths over Eversden et al. (2007) in that they had assessed disease activity rather than just improvements in functionality. However, it was not clearly verbalize whether or not improvements in Hydrotherapy group were statistically signifi under(a)sidet and sermon dosage, if long (4 weeks) could cause produced a great therapeutic effect.Thirdly, Bilberg and Mannerkorpi (2005) found significant improvements in muscle function and endurance of upper and set down extremities and grip force. However, this was not supported by an increase in aerobic capacity as indicated by their hypothesis and primary consequence treasure (Cycle Ergometer Test Astrand 2006). Unlike, Evers den et al. (2007) and Hall (1996) this study reported intensity of exercise (70% of HR) and addressed longer term effects (12 weeks). However, sample size was slight (46 patients) and temperature of pool was not specified, making it baffling to generalise entropy.Overall, there was curt reporting of depth, temperature of pool, type and intensity of exercises. Although, outcome measures differed between studies, they were appropriate for use (Al-Qubaiessy et al). Therefore, there is some evidence showing that Hydrotherapy plays a role in reducing pain (Hall et al. 1996). Finally, this spiritedlights the importance of using standardised exercise procedures, longer term-interventions especially as RA is a chronic condition. This forget help in making specific recommendations.Therefore, in accordance to PICO, my query question is The long term effects of using specific Hydrotherapy exercise protocols Aqua-Aerobics Programme and The enceinte-Ragaz Ring Methods for RA. A randomize d Controlled Trial.Research bearing From a mulish viewpoint, a tangled methods draw close pass on be best-suited for this study as pain is a multi-dimensional phenomenon.However, a positivist would postulate that this study should be carried out only objectively as this would suspend generalizable conclusions to be drawn (Brooms and Willis, 2007). Alongside this, they would argue that searchers are detached from the investigation, thereby reducing bias (Bryman, 2004). Contrastingly, an interpretivist would support a qualitivate approach which would allow greater and richer insight into patients perceptions of pain (Bryman, 2001).Therefore, yielding both qualitative and quantitative information pull up stakes help increase findings and reliability of results (Bryman, 2004). For example, this study go out be able to assess the subjective nature of pain whilst still detect the relation between pain and disease activity objectively. Thus, taking this stance, exit allow to a ddress the biopsychosocial approach rather just a bio checkup model of care objectively (Engel, 1977).Finally, an experimental, embedded design will be used in this study. Alternatively, an interpretivist would use a case-study that assesses an individuals experiences this will have high ecological hardiness but lacks the ability to produce generalizable conclusions. By employing a multi-faceted approach, it will strengthen causal inferences by providing the opportunity to observe entropy convergence or divergence in hypothesis tasteing (Abowitz and Tool, 2010).Research MethodIn line with Rogers et al. (2003), the embedded experimental design employ in this study will involve a two-phase sequential approach (Creswell et al. 2005). This will include qualitative analysis carried out before intervention to inform the development of the treatment and after to help explain treatment outcomes (Figure 1).Figure 1 Experimental Embedded Design. (Creswell 2005).Alongside this, an RCT wil l be used. In accordance to the hierarchy of evidence an RCT is suggested to be one of the most powerful in research (Akobeng, 2005) due to its ability to reduce try of bias and systematic error (Bryman, 2004 Suresh, 2011). Contrastingly, a cross-over design would be difficult due potential carry-over effects even with a fizzle period (Saks and Allsop, 2013).Intervention DetailsThe CONSORT statement will be used in commit to enhance completeness and transparency of the study (Schulz et al. 2010). For example, corrasion bias will be reduced through reporting drop-outs and reasons for this will similarly be include (Schulz et al. 2010). describe of eligibility criteria is essential to determine whether results can be applied to others in the same condition (Bluml et al. 2011). In this instance, patients (men and women) patriarchal 18+ (in line with the American College of Rheumatology) with chronic RA who meet Steinbrocker usable Class I, II, or III (Steinbrocker, 1949) will be recruited from NHS outpatient settings in the western Midlands.Those who sustain a steady drug intake for 30 age in relation to Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) 3 months and DMARDs will be included in the trial. Although injections and corticoid injections in the 4 weeks leading up to the study will not be permitted, drug changes and injections will be during this reflects the pragmatic nature of this study. Consequently, recruiting in this manner will increase ecological validity as it represents a real-world situation (Broom and Willis, 2007).Those, which have received physiotherapy treatment within 30 days of estimate will be excluded in order to avoid any carry over effects. Also, patients who have had joint-replacement surgical procedure within the last 6 months will be excluded. Likewise, contraindications of exercise and density in water needs to be taken into account (e.g. patients with ungoverned epilepsy or fear of water) will also be excluded.It is t rue that greater exclusion criteria can reduce generalisability of results. However, such steps have to be taken in order to eliminate occurrence of confounding data which could potentially have a negative impact on the results of the clinical trial (Broom and Willis, 2007)Group DetailsPatients will be randomized using sealed opaque envelopes with treatment allocation. Random sequence of numbers will be established through flipping a virtual coin (Eversden et al. 1996) to eitherHydrotherapy 1 (Aqua Aerobics Group) (Eccentric, Concentric Exercises).Hydrotherapy 2 (The Bad Ragaz-Ring Group).Home-Exercise group that continue with daily activities.Unlike previous research (e.g. Hall 1996 Eversden et al. 1996), this study will consider intensity at moderate level (70%) as it has been shown to demonstrate physiological improvements (Astrand, 1986) assessed via a heart rate monitor throughout sessions. Additionally, depth of pool will be just under chest height whereby 50%+ of bodyweight is offloaded through buoyancy and hydrostatic twitch has been suggested to reduce swelling at this level (Becker, 2009). Importantly, temperature will range from 33.5-35.5 degrees which is safe and sufficient enough to produce therapeutic benefits (Becker, 2009). Finally, treatment dosage will be twice a week consisting of 30 minute sessions for a 20 week period. This will address longer-term effects.Outcome MeasuresA research assistant blinded to the treatment allocations will evaluate the outcomes measures in order to reduce detection bias. Bilberg and Mannerkorpi (2005) used a C Reactive Protein (CRP) (i.e. high levels demonstrates active inflammation) in order to test assess disease activity. However, it is said that more than 40% of RA patients have normal CRP levels (Sokka and Pincus, 2009), thus decreasing validity and clinical applicability. Therefore, this study will use Magnetic ringing Imaging (MRI) as the primary objective measure due its ability to present visual asp ects of inflammation within the synovial membrane shown to be a superior method and very relevant for RA (e.g. stergaard, 2009) (Figure 1). This will be taken, baseline and post treatment for all groups.Secondary outcome measures will include Visual Analogue Scale (VAS) (Figure 1) assessed on a 10cm scale, whereby 0cm indicates no pain. This is widely used to assess rheumatic diseases and a number of studies have established data showing that VAS results are very reproducible (e.g. Dixon and Bird, 1981). Other physical measures will include the Ritchie Articular baron in order to assess joint tenderness intra-reliability of this test has been shown to be acceptable (Levy and Dick, 1975) and is easy to perform. Finally, aerobic capacity will be canvas through a submaximal test in accordance to Astrands Principle (Astrand and Rodahl, 1986) shown to have satisfactory reliability in RA populations (e.g. Mannerkorpi and Ekdahl, 1997). Both of which taken pre-post.statistical Considerat ions and AnalysisAnalysis will be completed via the Fishers exact test and continuous variables by Wilcoxon signed rank tests for within group comparisons. Importantly, data analyses will be completed according to the intention to treat principles.honorable ConsiderationsIn line with Beauchamp and Childress (2001) it will be essential to have applaud for autonomy. Respecting this value, means to protect participants through data protection/confidentiality and ensuring they are adequately informed about what is proposed. In order to keep data anonymised face-to-face details of quantitative data sets will be replaced with numbers. Most importantly, informed consent will be obtained before commencing the study to ensure participants are not subject to an intervention they do not want. To further see these requirements, an information sheet for participants will be written which will also state risks as well as what data will be used for.Conclusion The main advantage of this study i s that is assesses disease activity on a physiological level objectively and also observes the impacts subjectively via VAS scale an unpopular approach in the Hydrotherapy literature (E.g. Hall, 1996, Bilberg et al. Eversden et al, 2007). Findings from this study, will hopefully assist in creating structured and standardised exercise programmes that could be used throughout healthcare systems. Finally, limitations of this study include the high costs that are associated with MRI scans and Hydrotherapy facilities. Neverthe slight, this will address the longer term effects of Hydrotherapy for RA.Referenced MaterialAbhishek, A., Butt, S., Gadsby, K., Zhamg, W. Deighton, C.M. (2010). 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